Richard M. Fairbanks School of Public Health Theses and Dissertations
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Item Enabling Policy to Advance Black Maternal Health Equity Through the Use of Doulas in Indiana(2024-08) Brown, Jenell Nicole; Archer, Sarah E.; Jackson, Emily; Walter-McCabe, HeatherDisproportionately high maternal mortality rates (MMR) among Black women continue to be a significant public health equity concern in the United States, particularly in the state of Indiana, where Black women experienced the highest MMR at 156.3 deaths per 100,000 live births in 2021. In comparison, White women experienced 90.7 deaths per 100,000 live births in the same year (Indiana Department of Health, 2024). Equity recognizes that high-risk populations have different needs and disadvantages and aims to address disparities by providing targeted opportunities, resources, and support to account for these differences. Health equity is achieved when everyone can attain their full potential for health and well-being (World Health Organization, n.d.). Equality refers to equal access for everyone, which in turn perpetuates inequities. While not the sole solution to Indiana’s Black maternal health equity crisis, Doulas are an evidence-based solution to reducing racial disparities in maternal health outcomes. Building on the current body of literature, this dissertation explores how Indiana can enable policy to expand access to Doula care and integrate Doula services into maternal healthcare systems. Through the employment of qualitative, semi-structured interviews with Doulas and other key stakeholders, findings identified that current barriers in Indiana include a lack of a supportive environment to legitimize the profession, lack of Medicaid reimbursement and inadequate private insurance coverage, processes that “medicalize” Doula care, and the need for collaborative efforts with Doulas when crafting Doula-related policies. By leveraging a policy and stakeholder analysis, an implementation plan was developed to provide recommendations on how Indiana policy can advance Black maternal health equity through the use of Doulas. This research's importance lies in its potential to inform policy and practice in Indiana and provide foundational information for other states that have yet to begin incorporating Doula care into policy to advance maternal health equity.Item Physician Compensation Models and Quality of Healthcare Services in the United Arab Emirates(2023) Elrefaey, Mahmoud; Tierney, William Michael; Babich, Suzanne M.; Czabanowska, KatarzynaPhysicians working in different healthcare systems receive financial compensation by means of several structures (e.g., the salaried model, the fee-for-service model, and the revenue-share model) depending on how and where they practice. Most research on the relationships, if any, between physicians' compensation models and the outcomes of healthcare services has been conducted in North America and Europe, but no equivalent research has been conducted in the United Arab Emirates (UAE). The purpose of my exploratory qualitative research study was to address two open-ended research questions: 1) what are the perceptions of hospital stakeholders about the idiographic effects of different physician payment models on quality of healthcare services in the hospital? 2) What changes might be implemented to physician payment models to improve healthcare services in the hospital? I audio-recorded semi-structured interviews with a purposive sample of N = 17 stakeholders at one private sector hospital in UAE. The heterogenous or maximum variation sample included five hospital leaders, two financial or insurance managers, five physicians, two nurses, and three patients. I conducted a qualitative analysis and identified ten primary semantic themes by deductive reasoning to address the first research question. I based four semantic themes on a template extracted from the literature, specifically: 1) Physician Payment Models Implemented at the Hospital; 2) Environmental Context for Payment Models; 3) Stakeholders Affected by Payment Models; 4) Misuse of Payment models. I underpinned six semantic themes by the dimensions of healthcare quality proposed by the Institute of Medicine, specifically: 5) Payment Models and Safe Care; 6) Payment Models and Effectiveness of Care; 7) Payment Models and Patient-Centered Care; 8) Payment Models and Timely Care; 9) Payment Models and Efficiency of Care; 10) and Payment Models and Equity of Care. Subsequently, I synthesized the semantic themes and identified two latent themes by inductive reasoning, specifically: 1) Relationships between Physicians' Compensation Models and Healthcare Services; and 2) Proposed Changes to Physician Compensation Models. I propose innovative changes underpinned by Kotter's Management Change Theory and Roger's Theory of Diffusion of Innovations. I recommend future confirmatory research using a quantitative correlational design to validate these themes.Item Examining Policy Solutions to Address Barriers Impeding the Adoption of Universal Adverse Childhood Experiences (ACE) Screening in Pediatric Primary Care Settings(2024-05) Ball, Tristyn Denyse; Archer, Sarah E.; Coburn, Kenneth; Jones-Kelley, HelenOver 93% of adults in Western Ohio have experienced at least one adverse childhood experience (ACE). This figure is significantly higher than the national average of 61% of adults who have experienced at least one ACE. Exposure to adversity in childhood increases levels of toxic stress, impacts brain development, and creates a predisposition for a variety of psychological and physiological ailments known as ACEassociated health conditions. While many pediatric healthcare professionals understand the implications associated with ACE exposure, the integration of ACE screening in pediatric healthcare facilities in the region is limited. The study aimed to determine the barriers to implementing ACE screening in pediatric primary care settings in Western Ohio and identify policy levers to increase the integration of ACE screening and care among pediatric healthcare professionals. The study used thematic analysis to identify themes in the results, as there is limited existing research in this area. Key informant interviews were conducted with local pediatric healthcare professionals to determine their views regarding the potential barriers and facilitators associated with implementing universal ACE screening in their organizations. The results concluded that barriers around workforce shortages, perceived diminished patient relationships, time, ethics, reimbursement, and overall discomfort lead to low screening integration in local pediatric healthcare organizations. Ohio’s current pediatric healthcare infrastructure can be leveraged to ease the implementation of the statewide initiative. ACE screening can be integrated into Ohio’s Early and Periodic Screening, Diagnosis, and Treatment program, which provides guidelines for developmental screening. Further, advocacy for the integration of ACE screening in the American Academy of Pediatrics Bright Future Guidelines will increase the utilization of the tool. The current state General Assembly has introduced legislation focusing on ACEs, and with new streams of state tax revenue, the policy window to advance this initiative is open.Item Leadership Imperatives to Improve Access for Older Adults to the Meals-on-Wheels Programs in California and Florida, Post-COVID-19(2023-07) Powell, Naci; Stone, Cynthia; Bigatti, Silvia; Czabanowska, KasiaThe United States is witnessing a growing aging population stemming from medical advancements allowing people to live decades longer than the previous generations. The Older Americans Act of 1965 (OAA) was the first federal-level initiative providing comprehensive services for older persons. Title III-C: The Nutrition Service Program of OAA endeavors to “(i) reduce hunger and food insecurity among older individuals, (ii) promote socialization of older individuals, (iii) promote the health and well-being of older individuals, and (iv) delay adverse health conditions for older individuals. Title III-C2: the Home-delivered meals or MOWs program cannot keep up with the demands for their services and have waitlists across the U.S. This descriptive qualitative study used the multiple case study design. Two states with the highest population of older adults, California, and Florida, were examined. Semi-structured interviews were conducted via telephone, and post-reflection memos were created after each interview, along with the completion of a comprehensive document review. Interviews revealed that approximately 499 older adults in California and 22,520 older adults in Florida are waiting for access to MOWs. Kotter’s 8-Step change model was used to formulate a plan for change. This study contributes to the knowledge of the challenges faced by older adults and MOWs programs, and it also highlights how leaders responded to the COVID-19 pandemic.Item Expanding Access to Novel Antibacterial Therapeutics in Low- and Middle-Income Countries: Leveraging Donor-Funded Pooled Procurement(2024-07) Swenson, Jessica Emily; Archer, Sarah E.; Coburn, Kenneth; Houchens, ChristopherAntibiotics are one of the most significant advances of modern medicine, however, bacteria continue to evolve faster than new antibacterials are being developed. In 2019, 1.27 million deaths were directly attributable to bacterial antimicrobial resistance (AMR) globally—more than either HIV or malaria that year—with the highest death rates occurring in low- and middle-income countries (LMICs) (Murray et al., 2022). Because of limited returns on investment, multinational pharmaceutical companies have largely abandoned antibacterial development. This void has been filled by smaller product developers vastly located in the United States and Europe who have limited resources and experience in seeking licensure and commercialization in LMICs, where the need is greatest (WHO, 2021). When these smaller developers only seek regulatory approval in the high-income countries where they are located, they often cannot sell enough of their product to avoid bankruptcy because of the low volume of patients with susceptible infections there (Alm & Gallant, 2020). Building on the current body of literature, this study assessed the factors necessary to leverage an existing donor-funded pooled procurement strategy to expand its scope to include novel antibacterial therapeutics, with the goal of expanding access to these products in LMICs. Market access expansion would bring new products to patients where they are needed most while also ensuring financial viability for developers of novel antibacterials who struggle to retain financial solvency. A qualitative case study gathering expertise from individuals familiar with current procurement practices for novel antibacterials and donor-funded global procurement strategies for other infectious disease therapeutics elucidated that the Global Drug Facility (GDF) is the entity best positioned to expand scope to include novel antibacterials for AMR. An eight-stage action plan was developed to provide recommended actions, resource needs, measures of success, and an anticipated timeline over the next decade for GDF and a consortium of technical partners to implement the scope expansion. By pairing a market-driven access expansion initiative with a pragmatic approach to support financial sustainability of product developers, these critical medicines can be available for patients globally, and the AMR pipeline can support the demand for new antibacterials for decades to come.Item Availability of Behavioral Health Crisis Care and Associated Changes in Emergency Department Utilization(2024-06) Burns, Ashlyn Brooke; Yeager, Valerie; Menachemi, Nir; Vest, Joshua R.; Mazurenko, Olena; Salyers, MichelleOne in eight emergency department visits involves a behavioral health crisis. Yet, emergency departments are rarely equipped to meet the needs of patients experiencing a behavioral health crisis. Innovative care delivery models, such as behavioral health crisis care services delivered by mental health treatment facilities, offer a promising alternative to the emergency department. As decisions are being made around reimbursement and expansion of behavioral health crisis care models, empirical evidence on the relationship between these services and emergency department utilization is needed. The purpose of this dissertation is to 1) assess availability of behavioral health crisis care services across the United States; 2) identify community-level characteristics associated with availability of behavioral health crisis care services; and 3) quantify changes in emergency department utilization associated with availability of behavioral health crisis care services. In doing so, this dissertation identifies gaps in the nation’s existing behavioral health crisis care system and highlights the value of ensuring access to these life-saving services. As national implementation of the new 988 Suicide and Crisis Lifeline is underway, findings from this dissertation may help inform efforts to transform the crisis continuum and ensure access to care for all individuals experiencing a crisis.Item Stroke Training, Research, and Education Toward Capacity With Hydroxyurea (Stretch)(2024-05) Latham, Teresa Smith; Czabanowska, Katarzyna; Babich, Suzanne M.; Ware, Russell E.; Yego-Kosgei, FaithBackground and Purpose: Sickle cell anemia (SCA) is an inherited hematological disease characterized by chronic pain, susceptibility to infections, and significant morbidity and mortality, particularly among children living in resource-limited settings. Stroke is a complication of SCA that can be prevented through transcranial Doppler (TCD) ultrasonography, a screening tool that identifies children at risk, and treatment with hydroxyurea. This study will inform how public health leaders can mitigate stroke risk among children with SCA in sub-Saharan Africa and how TCD screening fits into a larger context of providing safe, effective care. Methods: Stroke Training, Research, and Education Toward Capacity with Hydroxyurea (STRETCH) utilized a qualitative design that included semi-structured interviews with TCD examiners and stakeholders. There were 17 interviews with TCD examiners who participated in a training and supervision program, TCD trainers, and clinical care providers from 6 countries across sub-Saharan Africa. Interviews were coded and analyzed for themes that were used to identify effective training and program strategies, and to develop a capacity-building model for resource-limited settings. Results: Participants reported satisfaction with the training program, noting that in-person training with sub-Saharan Africa-based examiners was preferable to initial training using a web-based platform, and that ongoing training, supervision, and technical support through collaboration between US-based and Africa-based teams was conducive to skill development. Participants described the major clinical and socioeconomic impact of SCA on children, families and communities and emphasized the role of hydroxyurea in preventing complications and decreasing burden on health systems. Results indicate a call to action for improved education for clinicians, families, and community leaders and stakeholder support for health policy to facilitate access to hydroxyurea. Conclusion: The complexities of healthcare infrastructure and the morbidity and mortality associated with SCA in resource-limited settings warrant a multifaceted approach to capacity building. The STRETCH model integrates education, policy development, and access to hydroxyurea as a holistic approach that leverages geographical partnerships and builds on existing resources in sub-Saharan Africa. By simultaneously addressing education, policy, and access barriers, public health leaders can work collaboratively toward building sustainable capacity that improves outcomes for children with SCA in these settings.Item Exploring the Coronary Calcium Scores in Indiana Firefighters from Risk Factors to AI Predictions(2024-05) Li, Mingyue; Han, Jiali; Monahan, Patrick O.; Wessel, Jennifer; Nan, HongmeiFirefighters, facing toxic exposure and mandatory personal protective equipment use, are at increased risk for cardiovascular strain. Coronary artery disease (CAD) can lead to sudden heart attacks, making early detection and risk assessment critical. Coronary calcium score (CCS), obtained via computed tomography, serve as precise indicators of pre-clinical CAD, and are linked to increased cardiovascular events and mortality. However, specific risk factors affecting CCS in firefighters remain underexplored. In my study, I utilized existing health data from Indiana firefighters aged 35-68, gathered during their health screenings at Ascension Public Safety Medical. Focusing on those with complete evaluations—including physicals, lab tests, fitness assessments, and CT scans for CCS — I first examined the clinical risk factors influencing CCS. Then, I explored the association between maximal oxygen uptake MaxVO2, an essential measure of aerobic capacity and cardiovascular fitness, and CCS among different age groups (< 45, and >= 45 years). Subsequently, I developed machine learning models using these risk factors to predict CCS. I observed significant positive associations between age, monocyte percentage, and CCS. Also, I identified significant positive associations between alkaline phosphatase and CCS. Higher MaxVO2 levels were associated with lower CCS, especially in firefighters over 45. Finally, utilizing these findings, I developed machine learning models to predict CCS and selected the most precise one. In conclusion, this research provides a novel perspective on the cardiovascular risks faced by firefighters. The associations and predictive models I've established not only contribute to the understanding of CCS in this population but pave the way for targeted interventions. These findings emphasize the importance of age, monocyte percentage, alkaline phosphatase, and regular cardiovascular fitness assessments and may influence future guidelines for firefighter health monitoring, ultimately aiming to reduce CAD incidence and enhance occupational safety.Item Home Health Agencies & Home Health Care: An Examination of Financial Performance, Quality, and Micro-Costing(2024-05) Brumitt, Gary Maurice; Vest, Joshua R.; Menachemi, Nir; Blackburn, Justin; Mazurenko, OlenaHome health represents a key healthcare delivery provider for millions of Americans. Amongst those receiving home health care, approximately 3 million are Medicare recipients. Home health agencies (HHAs) are a key provider as there are roughly 11,500 HHAs providing home health services ranging from skilled nursing care, disease management, physical and occupational therapies, and wound care. HHAs are mainly for-profit entities. Financial performance has traditionally been a source of study for other types of long-term care organizations with regards to organizational characteristics and quality of care outcomes. As a major provider of healthcare, it is worthwhile to evaluate the relationship HHA organizational characteristics have on their financial performance, as well as the construct of HHA financial performance on quality. The purpose of this dissertation is to consider HHAs from the perspectives of their organizational characteristics, financial performance, and quality. Therefore, this dissertation consists of three studies: (1) an observational, cross-sectional study that looks at the possible correlation between HHA organizational structure (for-profit vs. non-profit), chain status (affiliation with a parent company) and financial performance, (2) an observational, cross-sectional study examining the relationship between HHA financial performance and Home Health Compare (HHC) quality star ratings, and (3) a Time-Driven Activity Based Costing (TDABC) that assesses an at home oxygen monitoring costing for recently discharged COVID-19 patients. In summary, this dissertation contributes to the home health literature by examining HHA organizational characteristics on financial performance, which may also correlate with quality. Additionally, this dissertation provides information on assessing the costs of remote, in-home care options and the associated cost drivers.Item Investigating Cardiac Class, Extracardiac Anomalies, and Dysmorphology Patterns Predictive of Mendelian Genetic Disorders in Pediatric Congenital Heart Disease(2024-05) Helm, Benjamin Michael; Wessel, Jennifer; Han, Jiali; Landis, Benjamin J.; Ware, Stephanie M.; Wetherill, LeahCongenital heart disease (CHD) is the most common class of birth defects, accounting for one-third of all congenital anomalies. There is a need to understand risk factors early in the CHD life course, as half of all mortalities affect infants. Approximately 20-30% of CHD is caused by Mendelian genetic diseases, and genetic risk factors strongly influence health outcomes. However, genetics evaluations are underutilized and unstandardized. We leveraged a clinical program standardizing genetics evaluations for pediatric CHD. Using a test-negative case-control design, we investigated novel phenotypic predictors of patients with Mendelian genetic disorders. In the first study of 588 patients (96% ≤1 year, 20.7% with a genetic diagnosis), we found that dysmorphic status was associated with two-fold increased risk of genetic diagnoses being identified, after adjusting for extracardiac anomalies (ECA) status. In the second work, we developed and applied a novel dysmorphology score for quantifying dysmorphology burden in 1,001 patients (95% ≤1 year, 23.4% with a genetic diagnosis). Using multivariable logistic regression models, we quantified associations between dysmorphology score, ECA status, and genetic diagnoses identified later by genetic testing. A clinical prediction model was developed to improve risk-stratification of patients with genetic disorders more objectively and based on quantification of dysmorphology. Last, we developed a novel method of body region dysmorphology (BRD) classification and investigated how BRD patterns were predictive of cytogenetic and monogenic diagnoses. Dysmorphism of the face, forehead, neck, and hands/feet regions were associated with genetic diagnoses, while adjusting for ECA status. Surprisingly, dysmorphism of the forehead was the strongest predictor of genetic diagnoses, including both chromosomal and monogenic disorders. We found 23.4% (n=234/1001) of patients had genetic diagnoses following standardized testing, and our novel phenotypic predictors, i.e., BRDs and dysmorphology score, will improve identification of rare genetic disorders. However, 8.7-13.1% of apparently isolated/non-dysmorphic patients had genetic disorders identified by genetic testing, highlighting the limitation of phenotype-driven prediction of genetic diagnoses. This work builds a foundation for investigating novel phenotypic associations with genetic causes of CHD, and future research will assess how early recognition of dysmorphology, ECA status, and CHD class predicts other long-term outcomes.